Gaps in the Care of Open Fractures: An Indian Scenario

Abstract

Background/Purpose

There is a distinct lack of published studies evaluating the reasons for delay in definitive treatment of open fractures. This study aimed to determine the specific factors causing delay in the timely treatment of open fractures from the time of injury and to analyse the quality of treatment performed at the pre-hospital level.

Methods

In total, 250 consecutive patients with open fractures were assessed for time to surgery from injury and admission. The referred patients were analysed for distance of travel, level of referring hospital and appropriateness of care. The reasons for delay in terms of infrastructural- and patient-related factors were analysed individually and in combination.

Results

There were 37 direct patients (Group A) and 213 referred patients (Group B). Inappropriate care was present in 172 out of 213 (80.8%) referred patients. In total, 84% patients travelled more than 50 kms. The definitive surgery in referred patients was likely to be significantly delayed with regard to time from injury (29.84 vs 44.84 h, p ≤ 0.02). After admission, the time to surgery was greater than 24 h in 102 patients. Multivariate regression analysis determined that associated injuries and lack of fitness for surgery caused greater delay than non-availability of operation theatre or intensive care unit bed.

Conclusion

Delayed referral, inadequate pre-hospital care and delay in surgery due to patient- and infrastructural-related issues at tertiary centre were identified as critical gaps in open fracture care in India. The importance of appropriate basic knowledge about management of open fractures should be emphasized at all structural level of care.

Graphic Abstract

Introduction

India has a huge burden of open fractures with more than 4.5 million cases per year [1]. The successful outcome of open fractures depends on early and appropriate definitive care [2]. Although the 6-h rule is no longer a gold standard for definitive debridement of open fractures, the early administration of antibiotics and access to the trauma centre are of utmost importance [2].

There is a lack of trauma centres in periphery in India with specialized trauma centres present in major cities and in state capitals [3]. Our country also faces the problems of a defective referral system, dearth of trained professionals in primary and secondary healthcare centres [4, 5]. This results in a substantial delay in reporting to tertiary centres and incomplete primary treatment [6]. Once in a tertiary care setup, factors like non-availability of operation rooms and uncontrolled comorbidities needing optimisation are likely to further delay treatment. Additionally economic factors, non-availability of proper implants and other theatre supplies required for the surgery may hinder timely performance of definitive surgery [3, 5, 7]. To mitigate such delays, it is important to critically analyse the reasons for delay in open fracture surgery in a particular setting.

Studies evaluating the factors responsible for delay in open fracture care are lacking in India. This study was conducted to analyse the specific factors causing delay in the timely treatment of open fractures in the setting of a tertiary care referral centre and to analyse the quality of treatment performed at the referring centres.

Material and Methods

This prospective study was conducted in a tertiary care hospital in India with a dedicated round the clock orthopaedic operating team and shared anaesthesia teams with surgical trauma. Approval from institutional ethics committee was taken for the study (IEC/2018/0029, IEC Regn no.ECR-658/Inst/PB/214/RR-2017). All adult consecutive patients presenting with open fractures from January 2019 to January 2020 were included in the study. The exclusion criteria were patients with closed fractures, traumatic amputations, suspected pathological fractures and patients with previous fixation/definitive debridement of the same fracture.

The patients were divided into two groups: Group A; patients presenting directly to our hospital, and Group B; patients referred from primary or secondary care centre to our hospital. The demographic variables analysed included age, sex, site of injury, associated injuries and comorbidities. The Gustilo Anderson grade of fracture at presentation was also recorded in the two groups.

For patients reporting from other institutions, the level of referring hospital and distance of referral were recorded. The level of referring hospital was decided on basis of referral slip or on basis of history given by patient or his relatives, ambulance driver or police personnel. The management done at the referral site in terms of splintage, wound wash and any suturing and antibiotic administration was noted. Appropriate care was defined by administration of antibiotics, proper dressing and splintage and no suturing without debridement [1, 8]. It was also recorded whether a proper referral slip was provided to the patient or not. The timing of antibiotic administration and the type of antibiotic administered were noted if a referral slip was available.

At the tertiary care centre, the time between injury to admission, injury to surgery and the time between admission to surgery were recorded. The reasons for delay in surgery of patients beyond 24 h were recorded in terms of lack of available operation theatre on day of admission, concomitant injuries in terms of head injury, chest or abdominal injury, fitness for surgery, lack of ICU (intensive care unit) bed and economic factors.

Statistics

Normality of quantitative data was checked using Shapiro–Wilk test, and appropriate descriptive statistics were used for each category. Relevant parametric and nonparametric tests were used to compare the quantitative data, i.e. mean age, time of presentation to hospital (h), time from injury to surgery (h) and time from admission to surgery (h). Qualitative data in terms of sex distribution, education, side of injury, associated injuries, comorbidities, grade of fracture and reasons for delay in surgery were compared using Chi-square test/Fisher’s exact test. Regression analysis was done to measure the impact of each factor individually and in combination with other factors in delay of definitive treatment of open fractures.

Results

A total of 250 patients satisfied the inclusion criteria with 37 patients in Group A and 213 patients in Group B. Both the groups were closely matched with respect to important demographic profiles, comorbidities, associated injuries and grade of fracture (Table 1).

Table 1.

Demographic profile of patients

Variable	Group A Direct (n = 37)	Group B Referred (n = 213)	p value
Mean age	33.02 (95% CI 28.81–37.23)	35.19 (95% CI 33.12–37.26)	0.35
Male/female ratio	30:7	194:19	0.6
Education (≥ 10th)	19	91	0.42
Right: left injuries	25:12	152:61	0.63
UL/LL/both upper and lower limbs	9/22/6	24/145/44	0.09
Comorbidities	7	35	0.71
Gustilo Anderson
Grade 1	10 (27.03%)	36 (16.90%)	0.14
Grade 2	16 (43.24%)	91 (42.72%)	0.95
Grade 3A	8 (21.62%)	56 (26.29%)	0.54
Grade 3B	2 (5.4%)	22 (10.32%)	0.34
Grade 3C	1 (2.70%)	8 (3.76%)	0.75
Associated injuries
Head injury	1	12	0.64
Chest injury	1	3
Abdominal injury	1	7

The distance of referral was less than 50 kms in 34 (16.0%) patients, while it was more than 100 kms in 29 (13.6%) patients. In total, 150 (70.4%) cases were referred from a distance between 50 and 100 kms. The maximum proportion of patients were referred from CHC (Community Health Centre). The data concerning the level of the referring facility are shown in Fig. 1a.

Fig. 1.

a Level of referring facility. b Quality of care with regard to referring facility

The type of treatment given at the primary centre is highlighted in Table 2. Inappropriate care was found in 172 out of 213 (80.8%) patients. The quality of care with regard to referring facility is shown in Fig. 1b.

Table 2.

Treatment given at primary centre

Treatment	Done	Not done
Antibiotic*	71/213 (33.4%)	142/213 (66.6%)
Suturing without debridement	50/213 (23.5%)	163/213 (76.5%)
Splintage	173/213 (81.2%)	40/213 (18.8%)
Referral slip	171/213 (80.3%)	42/213 (19.7%)

*In patients without a record, it was considered that no antibiotic was given

The most common antibiotic administered was ceftriaxone in 37 (52.1%) patients, amoxicillin and clavulanic acid in 13 (18.3%), cefotaxime, ceftazidime and cefixime in 3 (4.2%) each, amikacin, cefuroxime and gentamicin, ceftriaxone and amikacin, amoxicillin in 2 (2.8%) each and ciprofloxacin, piperacillin and tazobactam, amoxicillin and gentamicin, cefuroxime and gentamicin and metronidazole in 1 patient (1.4%) each.

There was a statistically significant delay (p ≤ 0.003) in time taken from injury to admission in reaching tertiary centre in Group B patients as compared to Group A patients with mean times being 12.68 h [95% CI (9.61–15.75)] and 1.61 h [95% CI (1.03–2.19)], respectively (Fig. 2a). The average time spent at the referral centre was 8.6 h [95% CI (5.80–11.40)], and the average time of travelling was 1.86 h [95% CI (1.57–2.15)]. In total, 194 (77.6%) patients had a delay greater than two hours in admission from the time of injury. This delay was more likely (p < 0.01) to be in referred patients (n = 183) as compared to direct patients (n = 11).

Fig. 2.

a Time from injury to admission in two groups. b Mean time from injury to surgery in two groups. c Time from admission to surgery in two groups

The time from injury to surgery is highlighted in Fig. 2b. The mean time in Group A was 29.84 h [95% CI (22.81–36.86)], and the mean time in Group B was 44.84 h [95% CI (39.76–49.91) (p ≤ 0.02)]. The median time to surgery was 23 h in Group A and 30 h in Group B. 54.05% patients in Group A were operated within 24 h of injury as compared to 30.99% in Group B (p < 0.01).

The mean time from admission to surgery is shown in Fig. 2c. 59.2% of the patients were operated within 24 h of admission. All grade 3C injuries were treated within 6 h of arrival. The average time the patient is likely to get operated after admission was 31.97 h [95% CI (28.70–35.24)]. The mean time of 32.68 h [95% CI (29.04–36.32)] was higher in Group B as compared to 27.88 h [95% CI (20.70–35.06)] in Group A although it did not reach statistical significance (p ≤ 0.31). The median time to surgery after admission was comparable being 1335 min in Group A and 1380 min in Group B.

The reasons for delay in surgery after admission beyond 24 h are highlighted in Table 3. In total, 102 out of 250 (40.8%) had a delay in surgery beyond 24 after admission with 12 patients in Group A and 90 patients in Group B. The mean time to surgery after admission in these 102 patients was 51.15 h [95% CI (45.66–56.64)]. On regression analysis, independent variables (variance inflation factor, VIF < 2) causing delay were identified as non-availability of operation theatre, economic factors, non-availability of ICU bed, fitness for surgery (in patients with comorbidities) and presence of associated injuries, i.e. abdominal injuries, chest injuries and head injuries. The multivariate analysis was done to determine the impact of each factor on delay hours (Table 3).

Table 3.

Regression analysis for delay greater than 24 h with all variables in the model

Reason for delay	Number	Present* Mean (SD) in hours	Absent** Mean (SD) in hours	Coefficient (multivariable)	p value***
Non-availability of operation theatre	55	42.7 (23.8)	60.3 (28.9)	− 1.76 (− 11.80 to 8.28)	0.728
Economic factors	21	50.0 (19.2)	51.2 (29.5)	5.08 (2.97–27.18)	0.015
Non-availability of intensive care unit bed	13	66.8 (33.8)	48.6 (26.0)	8.05 (− 4.90 to 21.00)	0.220
Fitness for surgery	19	67.1 (25.8)	47.2 (26.8)	34.66 (22.46–46.86)	< 0.001
Head Injury	14	61.9 (38.8)	49.2 (25.2)	25.48 (11.37–39.58)	0.001
Abdominal injury	12	85.1 (38.6)	46.4 (22.4)	42.32 (28.93–55.71)	0.001
Chest injury	9	73.3 (47.1)	48.8 (24.3)	19.35 (3.65–35.05)	0.016

*When particular factor was present (with/without other factors)

**When particular factor was absent and delay was due to other factors

***Significant at p < 0.05, Wilcoxon–Mann–Whitney U test

The relationship between delay and number of reasons was determined. Spearman correlation coefficient showed that there was a moderately positive correlation (rho = 0.34, p ≤ 0.001). For every 1-unit increase in number of reasons, the delay increases by 21.19 h (Fig. 3).

Fig. 3.

Correlation between number of reasons and delay (hours). Spearman Correlation Co-efficient (rho = 0.34, p = < 0.001)

Discussion

Early antibiotic administration and early operative debridement are the cornerstones of successful treatment of open fractures [9–11]. Although many studies have commented upon the impact of timing of antibiotics and debridement on outcome of open fractures, few studies have analysed the pre-hospital factors leading to delay in definitive management of open fracture patients [12, 13]. Only one study has included patients from India and even in that study, outcome measure was time to admission rather than the time to definitive treatment of open fracture patients [13]. Likewise, there has been little comment on the adequacy of pre-hospital care in open fracture patients [14]. The present study identified three critical gaps in the management of open factures, i.e. delay in referral to final treating centre, inadequate treatment at the primary centre and delay in surgery at tertiary centre due to patient- and infrastructure-related issues.

Referral from Other Centres

In the present study, 85.2% of patients were referred from other institutions. The number of referred patients is quite high as compared to western population. Pollak et al. [2] reported that 38% patients of open tibial fractures were referred to trauma centre, while 62% presented directly. In contrast, Jergesen et al. reported a 51.4% rate of referral in a hospital setting in rural South Africa [15]. A higher rate of referral is an indicator of immature trauma system, and the contrast in direct admissions is seen in overall trauma population as well [14]. The western studies typically show that 30–35% people are referred [16] as against 50–70% in studies from India and third world countries [6, 15, 17, 18]. Developing countries have few fully developed trauma and tertiary referral centres, and this increases the proportion of referral patients [3, 16].

This fact is also reflected in the distances travelled by the referred patients. In our study, 84% of the patients were referred from more than 50 kms with 13.6% being greater than 100 kms. These findings are similar to other low resource settings. Jergesen et al. [15] in their study of 1055 patients observed that 38.6% of the patients were referred from greater than 50 kms radius. Radjou et al. [6] reported a mean referral distance of 52.81 kms, while Roy [18] had 20% of patients travelling greater than 50 kms with more than 5% patients travelling greater than 300 kms.

The mean time from injury to admission in the direct group of patients (1.61 h) was significantly less than the indirect group (12.68 h). The lancet commission for global surgery sets a target time limit of 2 h for admission to final care as a marker of adequate care in open fractures [9]. In the present study, there was a delay in hospital admission of greater than two hours in 194 (77.6%) of the patients. Even in an advanced trauma care setting Pollak et al. [2] reported a mean time from injury to admission of 7.9 ± 7.2 h for indirect patients as compared to 1.4 ± 1.3 h in direct patients. In a low resource African settings, one study showed a delay in referral of more than 72 h in 41.4% of the patients, while another study showed that 36% patients presented after 24 h of injury [7, 12]. The delay in referral led to a significant increase in times from injury to surgery in the referred group (Fig. 2b) with a median time of 30 h in the referred group as compared to 23 h in the direct group. Besides transportation time, unnecessary imaging for medico legal purposes, inappropriate therapeutic and diagnostic interventions, assessing an unsuitable medical facility and lack of inter hospital transfer protocols are cited as the most common cause of delay [2, 6, 11, 12].

It has been conclusively shown that establishment of trauma centres and formal trauma network reduces unnecessary admissions at non-specialist centres and decreases the time for assessing specialised care, thus improving patient outcomes such as time to skin cover, number of secondary procedures, hospital stay and deep infections [19, 20].

Pre-hospital Care

With such a high percentage of referred patients, it becomes critical that the quality of pre-hospital care is appropriate. Early administration of intravenous antibiotics, basic wound care and splintage are essential components of such care [21]. Unfortunately appropriate treatment was lacking in majority of patients in the present study. Inappropriate care was present in 80.2% cases (Table 2, Fig. 1b). The antibiotics were administered in 33.4% of the cases, and a wide array of antibiotics had been used. 19.7% of the patients did not have any documentation of the primary management. Rajdou et al. in their study had no proper documentation in 8% of the cases [6] and Roy et al. in 50% of the cases [18]. These informal referrals are another indication of immature trauma networks and inappropriate practices.

The poor quality of pre-hospital care is surprising as only 13.1% of patients were referred from a dispensary or a small local hospital. Rest of the patients were referred from hospitals which are expected to have a basic level of medical expertise and a capacity to manage surgical emergencies with functioning operation theatres. One reason could be chronic shortfall of doctors and surgical experts at CHC level which has been flagged in various studies [22, 23]. Another reason could be lack of awareness of trauma care protocols amongst doctors and paramedical staff [3, 8]. This is also borne out by the fact that a significant proportion of patients (23.5%) had a primary suturing without a formal debridement. Open fractures are contaminated so primary closure without definitive surgical debridement is absolutely contra-indicated [9].

This critical gap in pre-hospital care is a knowledge gap rather than skill gap. The primary care of open fracture can be efficiently carried out by a trained paramedic or nurse [24]. The deficiency in this area can easily be filled by educating primary healthcare givers on the importance of these measures in the management of open fractures. The basic management of open fractures should be treated as a core competence and suitably incorporated in training of nurses, OT staff, undergraduate and general surgical postgraduate training. Care of open fractures should be a part of the essential trauma care matrix. The guidelines for primary management should be enshrined in guidelines like Indian Public Health Standards (IPHS) Guidelines for Community Health Centres.

Time to Surgery After Admission

The 6-h rule may not be valid, but early debridement is essential and 24 h after admission remains a reasonable deadline to consider delay [25–27]. 40.8% of the patients in the present study were operated after 24 h of admission. In USA, two nationwide studies reported delays beyond 24 h of admission in 24% and 30% of the patients of open tibia fractures [25, 26], while a similar study in UK reported a delay in 18% of patients [28]. These reports are in contrast to Hailu et al. [12] who reported a delay in 71.1% of cases in Ethiopia.

The risk factors identified in order of frequency are non-availability of operation theatres, failure of patient to arrange implants, lack of fitness for surgery due to comorbidities, head injury, non-availability of ICU bed, abdominal injury and chest injury (Table 3). Presence of more than one reason in a single patient is likely to delay timely treatment further (Fig. 3).

The non-availability of operation theatre was the most common cause, but the delay caused was not as significant as other causes (Table 3). This can be attributed to the fact that a dedicated orthopaedic operating team was available round the clock. Rationalisation and redeployment of emergency resources based on trauma inputs with additional anaesthesia and intensive care resources including infrastructural and personal may mitigate this problem.

Economic factors led to a delay in 21 out of 102 (20.6%) patients. Universalisation of government insurance schemes for poor patients can address this problem effectively [22]. Further, efficient implementation of these schemes in the context of time-dependent interventions is also needed [22].

Diagnostic and therapeutic interventions for associated injuries may contribute to a delay in surgery of patients with open fractures [26]. The present study showed significant delays in patients with associated injuries and comorbidities. Other studies have reported similar findings. In an analysis of national trauma database of USA, it was seen that patients with additional thoracic injury or head injury, a greater injury severity score and initial admission to other surgical specialities had greater delays in initial debridement [27]. Admission to ICU was found to be a predictor of delay in another UK-based study [28]. Undoubtedly life-saving surgeries take precedence, but better coordination between surgical specialities with the aim of early orthopaedic intervention is needed. In contrast to the study by Namadari et al. comorbidities delaying fitness for surgery were a significant factor for delays to surgery in the present study. A balance between early debridement and level of physiological optimisation can be sought using a case-specific approach within a particular clinical context [26].

The present study has its limitations. The data represented highlight the situation at one tertiary centre and may not be generalisable. A multicentric study would further clear our understanding of the gaps in care of open fractures in India. The reasons for delay in pre-hospital settings were not explored, and only the time taken to reach the tertiary centre and management till then were evaluated. We did not assess the outcome of patients in terms of infection and requirement for secondary surgeries. We did not take into account time or day of arrival of the patient. The reason was the availability of similar type of service on all days. The strength of present study is a pre-defined protocol for prospective data collection and inclusion of all consecutive patients during the time.

Conclusion

Delay in definitive treatment of open fractures occurs both at hospital and pre-hospital stages. Lack of adequately functioning trauma networks leads to a delay in referral, and the quality of pre-hospital care is hugely inappropriate. In hospital, besides the availability of operating rooms and economic factors, associated injuries and comorbidities cause a significant delay. The most critical gap is at the level of pre-hospital care, and there is a crying need for adequate training of healthcare workers for early and efficient treatment of open fractures.

Funding

There is no funding source.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study informed consent is not required.